General Questions

Section A

Please Indicate Your Age Range

Please Indicate Your Race

Please Indicate Your Gender

Do Your Consider Yourself Overweight?

Do You Smoke?

Do You Drink Alcohol?

Have you experienced weght loss you cannot explain?

Any History of Cancer In The Family?

Cervical Cancer Pre-screening (Females Only)

Section B

History of cervical cancer in your family if someone has it, or had it?

Are you experiencing longer or heavier periods?

Are you experiencing unusual or smelly vaginal discharge which doesn't go away?

Are you experiencing Abnormal vaginal bleeding between periods?

Are you experiencing pain or bleeding during sex?

Are you experiencing vaginal bleeding after menopause?

Needing to pee more often?

Prostate Cancer Pre-screening (Males Only)

Section C

Any Family history of prostate or breast cancer?

Ever experience pain during urination or sex?

Do You Needing to urinate too frequently?

Any Swelling in legs or groin area?

Breast Cancer Pre-screening

Section D

Previous history of breast cancer?

Family history of breast cancer?

No children?

Previous radiation to chest?

Presence of breast lump?

Lung Cancer Pre-screening

Section E

Smoking history?

Previous work in the mines?

Previous cancer treatment?

Previous radiation treatment to head and neck?

Cough for more than 2 weeks?

Coughing up bloold?

Changes in your voice? e.g. hoarse

Colorectal Cancer Pre-screening

Section F

Family history of colorectal cancer?

Personal history of chronic? ( bowel related disease)

Alternating between constipation and diarrhoea?

Passing of black stools?

Anal bleeding?

Contact Information

Section G

Name

Phone

Email Address

Disclaimer

The result of the online self-screening does not constitute medical advice and is not intended to substitute for the independent professional judgment of the medical practitioners in the context of treating the individual patient. The E-Center makes no representation and assumes no responsibility for accuracy, efficacy, appropriateness, or suitability of screening results made available through the online self-screening platform. You are encouraged to confirm any test results obtained from or through the online self-screening. E-Center assumes no responsibility for any injury or damage to persons or property arising out of or related to the screening or for any errors or omissions.

For Support

Should you require support, contact e-Center on the following numbers.

Landline: +27 11 211 0715

WhatsApp: +27 78 816 5420

Alternatively contact Chris Hani Baragwanath’s Comprehensive cancer centre on

+27 72 120 0556
+27 64 751 3073<br / +27 64 751 3093

Section A

Section B

Section C

Section D

Section E

Section F

Section G

Cancer Screening Questionnaire

For further information or referrals
Call: 072 120 0556 / 064 751 3073

If responded "Yes" to any of Cancer risk factors, consider contacting e-center or the Baragwanath's comprehensive cancer centre on the numbers above for further investigation.

Section A

Section B

Section C

Section D

Section E

Section F

Section G

Cancer Screening Questionnaire For further information or referrals Call: 072 120 0556 / 064 751 3073

Participant Details

Cancer Screening Questionnaire

For further information or referrals
Call: 072 120 0556 / 064 751 3073